Comprehensive Treatment of Acute

Heart Failure
dr. Bambang Setiawan, SpJP
Physiology of the Heart

Heartspecialized muscular organ that rhythmically contracts and pump blood

Physiology of the Heart

• SV: Stroke Volume (ml/beat)

• HR: Heart rate (beat/min)
• CO: Cardiac output (ml/min)
• CO= SV x HR
• 5-6L/min
Cardiac Failure
“any heart condition that reduces the
ability of the heart to pump enough
blood to meet the body’s needs “

↑ Intracardiac Pressure

Hypoperfusi
Definition of Heart Failure
Fails to PumpAppropriately ?

 Heart failure is not a single pathological diagnosis,

 Heart failure is a clinical syndrome consisting of
cardinal symptoms that may be accompanied by
signs.
 It is due to a structural and/or functional
abnormality of the heart that results in elevated
intracardiac pressures and/or inadequate cardiac
output at rest and/or during exercise.
Kerley A: fine central linear interstitial markings
Kerley B: parallel horizontal lines abutting the pleura
Epidemiology of HF
• The prevalence of HF appears to be 1-2%
of adults
• Increases with age: ± 1% for those aged
<55 years to >10% in those aged ≥70 years
E.B. Reyes et al. / International Journal of Cardiology 223 (2016) 163–167
Diagnostic Heart Failure
Risk Factor : Hypertension, Atherosclerotic,DM, metabolic syndrome and
obesity, exposure to cardiotoxic agents, genetic variant or family history for
cardiomyopathy,
Terms & Classification of HF
Terminology Based on Left Ventricular Ejection Fraction
Terminology Related to the Time-course of HF
Acute/chronic  indicate time rather than severity

• Sign & Symptoms  treated

Stable Chronic HF • Remained generally unchanged at least 1 Mo

Decompensated • Sign & Symptoms deteriorates

HF • Suddenly or slowly  hospitalization

Acute De Novo • Acutely or Gradual  Sign & Symptoms of HF

HF in whom previously had no HF
Summary-Definition of Acute Heart Failure
• ESC : the rapid or gradual onset of symptoms and signs of Heart
Failure secondary to abnormal cardiac function.
• Requiring urgent therapy

• a clinical syndrome of new or worsening signs and symptoms of heart

failure (decompensated), often leading to hospitalization or a visit to
the emergency department
Other Terms of HF related to time-course
Acute Heart failure Syndrome (AHFS)

Acute(ly) decompensated Heart Failure (ADHF)

Acute decompensation of chronic heart failure” (ADCHF)

Hospitalization for heart failure” (HHF)

ACUTE HEART FAILURE

Epidemiology of Acute Heart Failure
• first reason for hospitalization in individuals aged 65 years or older in the Western
world
• Survival rate
• 4-10% die while in hospital
• 25-45% die within 1 year of admission
• High hospital readmission
• Typical length of hospital stay is 5–10 days
• High economic burden
• Care in hospital makes up most of the cost
Pathophysiology of Acute HF
• congestion
• signs and symptoms of
extracellular fluid
accumulation that result in
increased cardiac filling
pressures
Clinical Presentation of Acute HF
Clinical Presentation of AHF

1. Acutely Decompensated HF :
(Most common : 50-70%)
2. Acute Pulmonary Oedema
3. Isolated Right Ventricular Failure
4. Cadiogenic Shock
Diagnosis and Management of
Acute HF
What to look & Where to Start?
Diagnostic and Management Approach
Must be started promptly and in parallel !!

The initial evaluation of the patient with acute HF focuses on the

following critical aspects
1. establishing a definitive diagnosis of AHF as rapidly and efficiently as
possible
2. emergent treatment for potentially life-threatening conditions (e.g., shock,
respiratory failure);
3. identifying and addressing any relevant clinical triggers or other conditions
requiring specific treatment (e.g., ACS, acute pulmonary embolism)
4. defining the clinical profile of the patient (based on blood pressure, volume
status, and renal function) in order to rapidly implement the most
appropriate therapy.
Management AHF
Phase Management of AHF

Pre-Hospital

In-Hospital

Pre-Discharge
Phase Management of AHF
• Pre-Hospital :
• Clinical Judgement of AHF  Symptoms and Sign of
Decompensated HF
• Noninvasive monitoring :
• pulse oximetry, BP, heart rate, respiratory rate, and a
continuous ECG  within minutes and in the ambulance
• Rapid transfer of AHF patients to the most appropriate medical
setting
Phase Management of AHF
• In-Hospital :
• Diagnostic workup and appropriate treatment  promptly and in parallel
• Identifying and emergent treatment life-threatening
• Management starts with the search for specific causes of AHF
• Management based on main clinical presentation
• Disposition decisions : Discharge or in Ward or Need Intensive Care
Diagnostic Approach
Suspected Heart Failure?

Initial laboratory exams : troponin, serum creatinine, electrolytes,

blood urea nitrogen or urea, TSH, liver function tests as well as D-
dimer and procalcitonin when pulmonary embolism or infection are
suspected, arterial blood gas analysis in case of respiratory
distress,and lactate in case of hypoperfusion. as rapidly and efficiently as possible !!
Specific evaluation includes coronary angiography, in case of
suspected ACS, and CT in case of suspected pulmonary embolism
 Defining clinical profile and emergent
treatment for potentially life-threatening

identifying clinical triggers or specific

causes

according to different clinical presentations.

identifying clinical triggers or specific
causes

identifying clinical triggers or specific causes

according to different clinical presentations.

 Defining clinical profile and emergent
treatment for potentially life-threatening

identifying clinical triggers or specific

causes

according to different clinical presentations.

according to different clinical presentations.
according to different clinical presentations.
NS 500-1000cc IV
bolus 15-30 menit

according to different clinical presentations.

 Oxygen therapy and/or ventilatory support
• oxygen should not be used routinely in non-hypoxaemic  it causes vasoconstriction and a reduction in cardiac
output
• Oxygen therapy is recommended  SpO2 <90% or PaO2 <60 mmHg
Oxygen therapy and/or ventilatory support
Diuretic
• Intravenous diuretics are the cornerstone of AHF treatment
• ↑ renal excretion of salt and water  treatment of fluid overload and congestion
Diuretic
• Loop diuretics are commonly used due to their rapid onset of action and efficacy
 The maximal daily dose for i.v.
loop diuretics is : 400-600 mg,
though up to 1000 mg in
patients with severely impaired
kidney function.
 Combination therapy : loop
diuretic+diuretic with a different
site of action, e.g. thiazides or
metolazone or acetazolamide
Vasodilator
• Intravenous vasodilators, namely nitrates or
nitroprusside
• May be more effective in acute pulmonary oedema
is caused by increased afterload and absence or
with minimal fluid accumulation
• May be considered to relieve AHF symptoms when
SBP is >110 mmHg
Inotropes and Vasopressor
• For patients with LV systolic dysfunction, low
cardiac output and low SBP (e.g. <90 mmHg)
resulting in poor vital organ perfusion

Cardiogenic Shock
• Norepinephrine may be preferred in patients with
severe hypotension
• a combination of norepinephrine and inotropic
agents may be considered, especially in patients
with advanced HF and cardiogenic shock the use
of norepinephrine as first choice, compared with
dopamine or epinephrine
Opiates
• Opiates relieve dyspnoea and anxiety  as sedative agents
during non-invasive positive pressure ventilation to improve
patient adaptation
• Routine use of opiates is not recommended, unless in
selected patients with severe/intractable pain or anxiety
Thromboembolism prophylaxis

• Enoxaparin 40 mg subcutaneously once daily

• Unfractionated heparin 5000 units subcutaneously every 8 or 12 hours
• Rivaroxaban 10 mg once daily
Disposition Decision
Intensive
Discharge In Ward
Care
• Mild symptoms and signs • Other than Discharge and • Persistent, significant
of congestion Intensive Care Criteria dyspnoea or
• No renal haemodynamic instability
dysfunction,negative • High-risk patients (i.e.
troponin values and very recurrent arrhythmias,
low natriuretic peptide ACS)
(NP) levels • Need for intubation (or
• After a small dose of already intubated)
diuretics and some • Signs/symptoms of
adjustments of oral hypoperfusion
therapy • SpO2<90% (despite
supplemental oxygen)
• WoB ↑, RR > 25/min
• HR < 40 or >130 bpm,
SBP>90 mmHg
Phase Management of AHF
• Pre-Discharge :
• Treatment should be optimized  to keep the patient free of congestion
• Oral Optimal Medical Therapy should be continued, reinitiated, optimized unless contraindicated
• Studies  Discontinuation of Oral Optimal Medical Therapy  Higher risk for mortality and readmission

• It is recommended to have one follow-up visit within 1 to 2 weeks after discharge

Take Home Message
• Acute Heart Failure : a clinical syndrome of new or worsening signs
and symptoms of heart failure (decompensated), often leading to
hospitalization
• Diagnostic and Management AHF must be started promptly, as
rapidly and efficiently as possible and in parallel
• Treatment should be optimized and Oral Optimal Medical Therapy
should be continued or reinitiated
Thank You